This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Saturday, 18 February 2012

Random Thoughts and Stories

Once in a while I start blogging and then run out of steam. I have many many saved half posts stored on this blog that have never been finished or published. Here are some thoughts I had.

A Nurse can care for all of her patients some of the time, or she can care for only some of her patients all of the time but she CANNOT care for all of her assigned patients all of the time. There are just too damn many of them and constant interruptions to boot.

An example of this that springs to mine is what I saw happen to Mary, a Nurse on my ward in England. She had a patient start bleeding profusely out of his gastrointenstinal tract. Earlier in the shift she had recognised that he had potential to crash and she prepared for it. And he did suddenly crash. All of the sudden that patient was losing consciousness, his eyes were rolling to the back of his head and his skin was turning white. This was happening fast, like over a series of minutes. Mary had 15 other patients at this time who were all waiting on scheduled meds, treatments, discharge papers, requesting pain relief etc. Mary put the call out for her bleeder, got about 100 orders to initiate thrown at her and by the time he was on his way to the intensive care unit it had been 2 hours before she got back to her other patients. Then something else happened and she was again kept away from her patients for a further few hours. Staffing will not give a ward an extra nurse during a situation like this. It is one Nurse to 15 patients no matter what. That is what the ward is budgeted for. We don't get extra help if we suddenly have sicker patients. The number is fixed. The ratio can go down a Nurse but not up.

The family of the bleeding patient wrote a long thank you note to Mary. They were impressed at how fast she moved to get their father the help he needed, and how on top of things she was. They wrote a long letter to administration about how wonderful Mary was.

On the same day that administration got the letter applauding Mary they also received letters condemning her. These letters were from the other 15 patients that got the shaft because Mary's bleeder was sicker than they were. They condemned Mary as a vile uncaring Nurse who ignored them for hours and didn't bother to bring their meds on time.

This happens a lot. Unless you understand what is going on with your Nurse's (or doctor's) other patients and what it involves and time frames involved you aren't really going to grasp how it is going to effect your care. I might want to go over your medications and tests with you, but I can't if one of my demented patients just pulled out his central line and caused himself a pneumothorax. I might want to get to you with your pain meds but it ain't going to happen if one of my patients suddenly and without warning goes into a 19 beat run of Vtach on the monitor and I got to sort him out and transfer him to CCU. There is nothing I can do to stop those things from happening at the same time so many of you need me for something else. As you are always sharing your Nurse and Doctor with way too many other patients it might be a good idea to get to grips with the concept of triage and prioritisation.

My sister in law called me on the phone. She told me that she was 'JUST LIKE A NURSE' because her kid was sick and she stayed home from work to make him chicken soup and cuddled him on the sofa. "I guess I was a Nurse today just like you, Anne" she says.

I nearly fucking ripped her head off for saying that. First of all if you are not so laden with anxiety that your hair is falling out you are not anything like a NURSE. Being a Nurse involves being assigned way more patients that you can handle every single day, day after day.....some of them are so sick it's like if you blink twice they're dead. Many of them are non complaint and abusive, with extensive drug and alcohol abuse and psychiatric histories. You can't even come close to doing the things that you need to do for them because of their behaviour, the acuity on the ward in general as well as the short staffing yet you have total liability.

I wanted to say "Listen dumbass, when you spend 14 hours afraid that you are going to be held responsible for someone getting hurt or dying because you can't be 100 places at once then you will have some kind of clue about what being a hospital ward Nurse is about. Until you experience that complete liability and blame with no control you can just shut the fuck up. Taking care of your sick kid, dog, spouse, grandma is not the same thing at all."

Doctors have more stress but they also have much more control, which helps manage the stress. But anyway as you can see it doesn't take much for me to snap at family and friends with their dumb ass comments about "Nurses". The cousin who asked me what the hell it is a Nurse actually has to do at night "because all the patients are sleeping, right" no longer has a scrotum.

I feel nothing anymore. I was talking to a friend from school who is also a Nurse. I was telling her (Julie) about how the UK thinks that solving the lack of care in hospitals can be done by teaching nurses about empathy and compassion "the most important part of their job". Whatever. After a shocked silence she responded with "but my god, feeling is the first thing that has got to go if you are going to stay in a job like this, why don't they address RN ratios and resourcing". I agreed.

After a few years of general floor Nursing I began to feel nothing, completely numb. I watched my grandma die of old age and felt nothing. Honestly, I got to the point where I could have witnessed a plane full of kids crash and not even bat an eyelash. You just go numb and just try to survive. It's a defense mechanism. Some Nurses get like this after a few months of the job and with others it takes years. One day you just realise that you have no feelings anymore and you realise that you have to quit. People who leave bedside Nursing tell me that feelings do come back again eventually. Having got out of the short staffed clusterfuck hospital I worked in when in England, I have to say that I do believe that this is true. You can't put Nurses in these kinds of situations (21st century clusterfuck acute care) and expect them to be patient and empathetic. Like Julie said, those traits are the first thing that go. They have too. Nursing is a whole different ballgame from what it was in the 60's. Bedside Nursing is hell and everyone wants to escape. If all we dealt with was bedpans, drug rounds, shit and puke we would find our jobs easy and stay at the bedside.

And don't even get me started on the Uncle who said "I could never be a Nurse like you Anne, I would find blood and puke to hard to deal with" no longer has any eyes because I scratched them out. Poor Joe didn't know what hit him, he thought he was showing me a mark of respect by saying that. Blood and puke and shit and piss are probably the easiest aspects of my job. His comment was an insult.

I am sure lots of "Nurses" will come on here and take issue with what I am saying. But not one of them will be people who work as QUALIFIED Nurses in Med surg, general medicine, short staffed MAUs or heaving EDs. Come to acute care/general medicine and then get back to me is my preemptive comment to them. I have lived it and I have done my research. What I say is true. People who think that Nursing is a soft service style job for soft people with strong stomachs are assholes.

Mentioning my grandma in this post reminds me of something else I will post about. And that post will probably be more funny than disturbing.

77 comments:

ICUmurse
said...

Hey Anne, long time no see. It's only getting worse here but sure you are observing the pieceofshitwankpot that is the DM from afar. I had enough, even of ITU and jumped ship to research - vastly less stress, 9-5/flexitime as I want it, some of the best colleagues I have ever had and lovely willing patients who are grateful for the opportunity to take part (and aircon!) The best/worst bit? TWO whole pay grades more than at the bedside. Have I sold out? Probably - I still give my patients the best but fuck it, the NHS has had it's pound of flesh from me, nearly taking my family as well so screw 'em. It is reaching a point where the only nurses left at the bedside will be those unable to escape - many due to stubbornness (til they fucking die at 55) but more due to being shite. Or being HCAs. So it keeps going round and round. Headlines like 'David Cameron ORDERS nurses to demonstrate compassion' make me want to go all political assassin. Oh, and Peter Carter is still a cunt x

Ahh your post reminded me of the post I was going to write about filling in those hourly rounding sheets that Cameron talked about.

We JUST started having to fill in those hourly rounding sheets over here. Every hour you are supposed to go into a patients room and check off that you have been there and done stuff.

Fucking impossible even with 6 patients.

But if a patient falls out of bed, arrests, whatever and the initials are not on the paper then it's your fault. Even if you are tied up down the hall with an admission or very sick patient.

How the hell are NHS nurses are going to manage that with 15+ patients a piece?

Good for you for getting out of bedside Nursing even if it means a paycut. Thousands before you have done the same.

The staffing levels are better here but we also have many of the same issues that you do. The patients I have on the floor here are more acute and the charting is 10 times worse. Everything moves a lot faster as well.

Best of luck. I'd kill myself if I had to stay at the bedside in the NHS with 15 patients per RN. Its not a matter of working hard. It's the liability and the abuse you take when the patients and families don't get their unrealistic expectations met.

Oh wait you are getting paid better? Even better!!! I could make 15,000 more a year working a 9-5 job for an insurance company nearby reviewing charts in an office with a cup of coffee. No psycho family members, no life and death decision making. Just one sweet little task at a time and lunch out.

No weekends, nights, holidays, no doctors, no cardiac arrests, no admissions etc etc. Just chart reviews. This company scouts out the hospitals looking for burned out RNs. They have a massive hiring thing on at the moment and just about every RN on my floor has applied. I spoke to a friend who's daughter is a Nurse and works there and she said that she feels like a human being again.

Nurse Anne, as ever you are so right. I went into education when I burned out & couldnt do it anymore but still feel guilty for selling out. And until sonething is done about staffing levels anyone who can get out does & who does that leave ?

I work in a reasonably staffed NHS ward, and I agree with you. The hourly rounding sheets are crap anyway. I just sign them all for each hour when I do my notes. Management have actually stated to us that they don't care if we don't check the stuff, as long as we sign the sheets. OK then.

I am so glad I decided I wasn't cut out to be a Nurse! My experiences of the patient side of the NHS have confirmed to me that you are all amazing people being asked to do too much with too little. Chin up - your patients appreciate you (unfortunately it's the ones who whine about everything that you hear about) Keep it up - the world is a better place because some of you care enough to care.

I'm a 2nd year student nurse. I think your blog is brilliant...but soul destroying at the same time as to how realistic it is!So I'm trying to formulate a plan as to where to work given the choice when I qualify, somewhere where I have the resources and support to do the job properly with the least amount of patients to manage at any one time.I may be extremely naive in asking this but are there any areas/specialities within NHS Nursing at all where this is at all possible?

OK Anne I hear what you're saying even if your language is foul. I also agree with most of it but what I want to know is what are you actually DOING about it? You're obviously passionate about nursing and want to do the very best by your patients but venting your spleen on a BLOG, whilst cathartic, is not changing anything.Many problems are the same on both sides of the Atlantic partly because the UK imported changes in practice from the States! All nurses need to mount a campaign for improved staffing levels and proper training for all but especially HCAs. HCAs also need to be regulated so they can be held accountable. You're not Militant until you start taking action

this very tired nurse with 30 years experience is being "performance managed" which is how a failing organisation shifts the blame onto an individual who fails to keep up with an impossible workload despite working late every shift to catch up-thanks for nothing guys!

I hear you! I too am an ex-ICU nurse, escaped into research. When I arrived at my desk on the first day of my research post I was dead inside. Slowly I have made a comeback. Now I can safely say that when at work I am a lioness, and my patients are my cubs. And I have actually started admitting to total strangers that I am a nurse, I used to lie before and give another job, just to avoid the inevitable conversations time and time again. Be interesting to see what happens now that he health bill has been bullied through by our esteemed unelected dictator. I still can't bring myself to give a shit anymore. I feel like when the NHS finally goes, and can stick a massive two fingers up and shout 'told you so, you stupid, stupid people!!!' (perhaps I am not as recovered as I believed I was...)

As much as three quarters of hospital staff are usually burdened with some sort of billing-related work in a traditional billing system. Opting for electronic medical billing solutions (ones that come with free EMR plans) that fit easily into the healthcare business' workflow are key to freeing up staff resources.

I blog from the other side of the fence, and was delighted to come across your blog. I've sat here and read for a while with great interest. I've lived in hospitals (literally the last stay with my son was 8 months with no break) I've seen and heard and been caught up in things that no one will ever admit to anyone that matters.

I have also worked for the NHS. I find the black humour it instilled in me made me suitably resiliant to be able to survive my long stays now.

I do however echo the other commenter that asks what you're doing about it. It seems a shame to recognise the flaws, but not attempt to do something about it.

When I arrived at my desk on the first day of my research post I was dead inside. Slowly I have made a comeback. Now I can safely say that when at work I am a lioness, and my patients are my cubs. And I have actually started admitting to total strangers that I am a nurse, I used to lie before and give another job, just to avoid the inevitable conversations time and time again. Be interesting to see what happens now that he health bill has been bullied through by our esteemed unelected dictator.You're not Militant until you start taking actionIn Home Care NewPort Beach CA

Ive just found your blog whilst desperate to leave nursing, its exactly as you say it is and it depresses me how the public treat nurses like crap only to denounce that nursing was better 30 years ago....yeah I wish I was a nurse 30 years ago when all they had to do was actualy provide care for patients. now its full of so much bullshit. Im so depressed right now.

I'm an hca on a ward where our nurses have been told that they don't have to help out with basic care if they don't want. so they don't.the rounding tools are done by us. the monitoring of skin, obs, mobility etc is done by us. we manage all the 20 plus feeds with 4 hcas and complete all diet, food, input etc charts. we answer all the phone calls, update most of the families, clean, cook, run to pharmacy, run errands for doctors, fill in evaluation forms, do all the dressings, take bloods, do all the bm's, do all washes, take handovers over the phone, go without a break so the nurse's don't have too, take all samples and send to lab. so please do not imply that all hcas do not know what they are doing while all nurses are run off their feet. our nurses are run off their feet most of the time, but we are too and we do our damned hardest to help. it's not about " I work harder than you do " it's about working as a team to provide the best care possible.on a normal day I have 11 patients in my care, and I alone will manage all the feeding, charts and obs on those patients. if a nurse is having a shit shift, it's down to not having a decent hca to support them.

An intriguing discussion is definitely worth comment.I do believe that you need to write more about this issue,it might not be a taboo subject but generally people don't speak about such issues. To the next! Cheers!!

Hey there, I think your site might be having browser compatibility issues.When I look at your blog site in Chrome, it looks fine but when opening in Internet Explorer, it has some overlapping. I just wanted to give you a quick heads up!Other then that, fantastic blog!

Would you be interested in trading links or maybe guest writing a blog post or vice-versa? My website goes over a lot of the same topics as yours and I think we could greatly benefit from each other.If you might be interested feel free to send me an e-mail.I look forward to hearing from you! Awesome blog by the way!

of course like your web-site however you have to test the spelling on several of your posts.Many of them are rife with spelling issues and I in finding it very bothersome to tell the truth on the other hand I'll surely come back again.

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In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.